Ruminations by a non-academic general surgeon from the heart of the rust belt.

Sunday, January 4, 2009

Full Disclosure

Via KevinMD there's a link to a blog by an OB doc named Dr Tuteur. Dr Tuteur discusses a dinner party conversation this past New Year's Eve she had with friends about a doctor's responsibility to inform a patient of an error made in his/her care by a previous doctor. The example they use is: Patient with advanced lung cancer seeing an oncologist. Oncologist notices that a CXR from a few years ago demonstrates the tumor at an early stage. The patient now has has unsalvageable metastatic disease. Question: ought the oncologist inform the patient that an error had been made, that the cancer was missed by the referring primary care physician and the radiologist?

First of all, if it's New Year's Eve and you find yourself at a dinner party where the dominant topic of discussion is medical ethics, it's probably safe to assume that you've made some sort of horrible mistake in choosing your dinner companions and you ought to explore all possible modes of escape from said gathering. I mean, it's New Year's Eve right? Let's drink some champagne and rant about the Browns and tell a few funny stories.

But an issue like this is generally handled in an overly simplified fashion. It's a nice little thought experiment and well reasoned arguments can be made for telling versus not telling but the reality of such situations is usually much more nuanced and complex. To aver that one ought to always inform a patient of a past error is dangerously rigid and dogmatic. Likewise, to maintain that you would never reveal such information to a patient only serves to create the impression that physicians just look out for each other and are not a patient's advocate.

It's not a black and white moral conundrum. How do we define "error" and "mistake" in relation to "negligence"? Whose responsibility/obligation is it to inform the patient? What purpose is served by full disclosure? Is it always in the patient's best interest to know everything that has transpired? Will there consequences for those doctors who choose not to inform on their colleagues?

Consider the following more realistic examples:

1. You see a patient referred by your cash cow OB/Gyn with regards to a palpable breast mass. Upon review of last year's mammogram it appears that someone neglected to inform the patient that BiRADs IV calcifications were noted in the area where there is now a palpable mass. The mammogram had been ordered by the OB/Gyn. You've worked with the OB/Gyn for ten years and you've never had a situation where you questioned his management of a patient's care. He is universally recognized as an excellent physician and is well respected by the community. Moreover, he sends you at least 10-15 cases a month. What do you do?

2. You see a consult in the ICU for gallstone pancreatitis. The patient is in multiple organ failure and the CT scan suggests pancreatic necrosis. Upon reviewing the electronic medical record, you observe that the patient had been admitted multiple times over the past three years to the hospital by the internist for minor attacks of cholelithiasis and gallstone pancreatitis. A surgical evluation had never been requested. The internist has just finished a very emotional family meeting where he informed the wife and children of the patient's dire prognosis. Internist's eyes are swollen and red cracked. She has been the physician for everyone in this family for 15 years. Are you morally obligated to inform the family at this very delicate time that their trusted doc screwed up? Or ought you to show some tact and send them an anonymous letter in the mail three months later along with an attachment listing area malpractice attorneys?

3. You're the ID consultant seeing a patient with perianal sepsis. Cultures from the I&D site are growing MRSA. The general surgeon managing the case just has the patient on Unasyn. The cultures have been available in the chart for 4 days. You were consulted because the patient had persistent erythema and a leukocytosis. Do you simply make the necessary antibiotic adjustments? Or inform the patient that the general surgeon neglected to respond in an appropriate fashion to culture results that were freely available days ago?

10 comments:

As a layperson, I would like to know the truth as YOU have found it to be. I am probably not typical in that I understand that mistakes are made and physicians are not perfect and also I am not a litigious person.

In case #1, Could it be that the OB/GYN didn’t think it was significant enough (in his opinion) that it could wait for the following years scan? Maybe he needs to be pointed to reference materials or a CME in that area.

Case #2 Had a surgical consultation been requested at some point during that 3 year span of admissions, would the patients dire outcome have been altered? If so, the Internist certainly should be told as it is apparent that the thought didn’t cross her mind. Sounds like a pretty blatant error of judgement.

Case #3 I would tell the patient they are on the wrong antibiotic according to their C&S. If they asked me why, I would tell them I don’t know why their primary surgeon wasn’t aware of the C&S results as they had been charted for several days. It is truthful and puts the patients care (somewhat) back into their own hands to follow-up with the physician of record.

Like I said, I am not a physician so I may be way off base here but as an outsider looking in and as someone that has had to scramble to help physicians document things long after the fact, it does bother me when a patient is left out of the loop of their own care.

I worry that your justified repudiation of the easy yardsticks of "never" and "always" really only results in moral relativism. The "nuances and complexities" that are imported into the scenarios provided are predictable and reinforce unfortunate stereotypes (such as constant concern with money and litigation, as well as the assumption of ineptitude on the part of the patient's ability to reason "correctly", if provided the truth in the form of facts).

I don't want my dctors to substitute their judgment and values for my own in situations that involve such personal things as my quality of life, the details of my days. I don't want my doctors to function as some sort of ad hoc grand jury, either.

The doctor does not get to wear the mantle of Omniscient Narrator of the lives with which s/he is involved -- especially if the plot changes due to determinations of, say, the litigious bent of the patient, the family, or the situation.

Major props for even discussing this! I have an excess of experience in interpreting behavior in scenarios such as you present. You know that "do no harm" thing? The greatest harm ever done to me came in the form of withheld information, lies, and tongues that were held (with the excuse that it seemed "in [my] best interest at the time.").

As doctors, you can only do your best. I know that some patients do not understand this, that there is a wrong-headed culture of lawsuits and blame that has eroded much of the willingness of doctors to extend themselves unnecessarily. But moral relativism is absolutely the wrong response and serves only to underscore the mistaken impression of social and intellectual snobbery as the driving forces behind the personal ethic of physicians.

Thanks so much for this post. I am going to pop some corn, put my feet up, and wait for the arguments to begin!

Bianca- Thanks for the reply. I didn't intend for this post to function as a justification for physician secrecy. Instead I wanted merely to point out the disingenuousness of the original case study. Rarely are we going to deal with a situation where Physician W sees Patient X and discovers that a clear error was made by unknown Physician Y and is compelled to inform Patient X of such malfeasance. The "nuances and complexities" are the very essence of the ethical dilemmas that we face in real life. Reality is not a parlor game.

I don't know the answer to this question. I do know that each situation is different and real life/real people cannot always be broken down into neat little formulaic "moral codes of conduct". As individuals this is what we will encounter and we will have to make our choices come what may. Moral relativism indeed, and not necessarily in a perjorative sense...

And that's what makes me nervous. Is this something that really needs to be legislated? Is taking a complex indidualized situation and subjecting it to an inflexible behavioral dogma always going to be in the best interest of the patient and society as a whole? That's the interesting aspect to all this....

OHN- I like your thinking on the 3 case studies. Physician to physician confrontation seems to me to be the best intial move...

"Physician to physician confrontation seems to me to be the best initial move"

Is this not the definition of a profession, i.e. a group that regulates its own members and holds them to a certain standard?

In each case, it seems that only sadness and accusations can arise from full disclosure. Patients deserve to know about their care, but the belief that both physicians and science are somehow infallible, the erosion of which belief may go far to explain the surge in Complementary and Alternative Medicine, can only lead to litigation. Diagnoses are missed. Accidents happen. It's not hard for someone to understand that a physician can miss something on someone else's chart. However, when that mistake is made regarding the patient's own chart, it's nearly impossible to understand. Everyone wants to think that accidents happen to other people.

Depends on if the guy who made the mistake is one of those holier than though jerks who thinks their feces smells like Chanel #5...Otherwhise I like to think we're all a band of brothers who'll charge a machine gun nest or fall on a hand grenade for the home team....and yeah, I've done my Mother Superior Dance pointing out colleagues mistakes, and had my own pointed out as well..I still can't believe that radial head fracture I missed in 1989....pointed out to me tactfully the next day by a grizzled PA, "FAT PAD SIGN???" Sure, I had treated the guy conservatively, and the Orthopod probably wouldn't have pinned it till the next day anyway....still, on some moldy DOD SF600 is my new doctor signature under a "No FX" notation for the Xray....

You have done a great job of explaining this from the doctor's view point but you have neglected something very important. As patients, we don't have to be told straight out that a mistake has been made. We already know when it happens.

For instance, if we have been seeing an onc. for a certain cancer and 2 yrs later we are diagnosed stage IV lung cancer, unrelated to first cancer, we know someone missed something 2 years prior. If it has mets to bones, ribs, brain and etc. It was sure there 2 yrs. ago. The doctors don't tell you, in exact words, it was missed, but in their own way they will at some point. Usually by saying something like, "you have had this for 5-10 years for it to be at this stage." At that point, you call the hospital where your scans and x-rays were done 2 years prior, and get copies of everything, including written reports, and BINGO, there it is.

This is an extremely bad situation for patients. To be dying and not have anyone acknowledge a mistake, or offer an apology, just seems wrong. We aren't all sue happy people, and a little honesty can make up for a lot.

As a student not yet working in healthcare, these are pertinent questions to me. Certainly I'll find errors with diagnoses & prescribed treatments during my career as a nurse. I would hesitate to assume negligence or malpractice if I saw a mistake. Physicians are usually trying to provide the best service they can, but are susceptible to error like anyone else. The difference is that in their professions, as it will be in mine, mistakes can potentially lead to death.

My first instinct would be to go directly, and privately, to the physician whom I suspect made an error. Perhaps there is something I have missed or misunderstood. In some cases (unlike the examples), there may be time to corect mistakes. Of course, this blog was intended to describe issues between physicians, and nurses have different training & roles, but I agree with Peter that often "only sadness and accusations can arise from full disclosure."

Fellow Buckeye, is my thinking, or understanding of the topic, flawed?How do you feel nurses should respond to situations like these? Please excuse me if these questions from a student seem elementary.

Also, OHN said s/he "has had to scramble to help physicians document things long after the fact." That sounds like being asked to falsify documentation to me, and is an even bigger (legal as well as ethical) dilemma. What happens if turning a blind eye leads you toward this course of action? It seems a simple error in diagnosis or treatment could lead to more serious errors of judgement. What are your thoughts?

Hey, I saw a pretty glaring error a few years ago, probably still within the Statue Of Limitations..This particular Hospital actually had a Pharmacist assigned to the Code Team (Only 9-5 Mon-Fri of course) who would personally pick out the drugs the M.D. running the code wanted...only problem is instead of "EPI" she gave "Lopressor", honest mistake, they were both 1mg, and act on the same receptors, albeit in opposite ways, Patient didn't do well, Died in fact. Hmm whats the name of that Malpractice Lawyer....

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